間質性膀胱炎的中醫治療 豐原醫院中醫科 張盈瀅醫師

 以尿頻、尿急、尿痛和尿意不盡等尿路刺激 症狀為臨床表現  多見於西醫學某些泌尿系統的疾病，如泌尿 系統感染、泌尿系統結石、泌尿系統腫瘤以 及乳糜尿等疾病  在臨床表現為尿路刺激症狀為主者

西方醫學觀點

引起間質性膀胱炎的原因  至今仍不明

IC 可能的致病機轉  發炎後之自體免疫反應過程： 曾有的膀胱發炎導致膀胱璧受損，並產生自 體免疫反應。此自體免疫反應導致膀胱黏膜 下及肌肉層後續之發炎及纖維化。 (Sant, 1999)

IC 可能的致病機轉  膀胱表皮功能異常  膀胱的黏膜內皮是由類似肝素的黏蛋白類組成 （ glycosaminoglycan, GAG ），可防止細菌粘住膀 胱壁。  Parsons,1994 ，認為 IC 是由於各種毒性或酸鹼度改 變、或膀胱過脹導致膀胱表皮滲漏性增加（缺乏 GAG 層所導致），使尿液裡的有毒物質及鉀離子進 入膀胱黏膜下之感覺神經，導致膀胱疼痛及炎性反 應。

間質性發炎  病毒感染  過敏性免疫反應 /auto-immune reaction  立克次菌

中醫觀點

 依照臨床症狀表現，間質性膀胱炎隸屬於中 醫 “ 淋證 ” 的範疇。  最早在秦漢時代的《皇帝內經》一書中即有 關於淋證的記載。  淋證的症狀描述： - 小便頻數、短澀，淋瀝不暢，小腹拘急引痛

中醫觀點  《血證論》 — 第四卷血下泄證治六條 - 尿血 — 第六卷失血兼見諸證 - 遺精、淋濁

 尿血  內容：膀胱與血室。並域而居。熱入血室。則蓄血。熱結膀 胱。則尿血。尿乃水分之病。而亦干動血分者。以與血室 並 居。故相連累也。其致病之由。則有內外二因。  一外因。乃太陽陽明傳經之熱。結于下焦。其証。身有寒熱。 口渴腹滿。小便不利。溺血疼痛。宜仲景桃仁承 氣湯治之。 小柴胡湯。加桃仁丹皮牛膝。亦治之。  一內因。乃心經遺熱于小腸。肝經遺熱于血室。其証。淋秘 割痛。小便點滴不通者。呼赤淋。治宜清熱。治心經遺熱。 虛煩不眠。或昏睡不醒。或舌咽作痛。或怔忡懊 。宜導赤飲。 加炒梔連翹丹皮牛膝。治肝經遺熱。其証少腹滿。脅肋刺痛。 口苦耳聾。或則寒熱往來。宜龍膽瀉肝湯。加桃仁丹皮牛膝 郁金。尿血治心與肝而不愈者。當兼治其肺。肺為水之上源。 金清則水清。水寧則血寧。蓋此証原是水病累血。故治水即 是治血。人參瀉肺湯。去大黃 …

 遺精  內容：世謂上吐血。下遺精。其病不治。謂其上逆 下竭。立見消耗也。然病此者。但未沉久。猶可圖 治。蓋遺精失血。  雖是兩病。其實一而已矣。精者腎中陽氣所化。乃 天一所生之癸水也。女子十四。則癸水至于胞中。 而沖任兩脈即通。將心火所化之血。轉輸入胞。與 癸水交合。水從血化。是為月信。男子十六。則癸 水亦至于胞中。而沖任兩脈。亦輸血入胞。與癸水 合。血從水化。是謂之精。胞者精之舍。即血之室 也。吐衄者。是胞中血分之病。遺精者。是胞中水 分之病。血與水。上下內外。皆相濟而行。吾已言 之屢矣。故病血者。未嘗不病水。

 淋濁  內容：淋者小便短數。淋瀝不通之謂也。單 病此者。自有諸書可考。血家病此。特其兼 見者耳。然二便為消息之門戶。若一閉塞。 則上中焦不得消息。故傷寒論。有言急下者。 有言當利其小便者。有言有小便則生。無小 便死者。無一不吃緊于此。此水病也。水與 血相為倚伏。吾已言之屢屢。單病血。不病 水者易愈。以水調。則其血雖病。猶有水以 濡之也。若病血。而又累及于水。則上而喘 咳。外而腫熱。下而淋濁。均不能免。水病 則無以濡血。而血証亦因以難愈矣。

中醫觀點  依其他兼症表現，淋證又可再細分成六類： 1. 熱淋（小便灼熱刺痛） 2. 血淋（血便） 3. 膏淋（小便渾濁） 4. 石淋（尿路結石） 5. 氣淋（膀胱功能失司） 6. 勞淋（久病正氣虛衰）

1. 熱淋  症狀：小便短數，灼熱刺痛，溺色黃赤。  兼症：腰痛拒按、寒熱起伏、口苦、嘔噁、 便秘，苔黃膩，脈濡數。  病機：濕熱蘊結下焦，膀胱氣化失司。  治法：清熱利濕，通淋。  主方：八正散。

2. 血淋：  實證  症狀：小腹澀痛，尿中有血或尿時夾有 血塊，疼痛滿急加劇。  兼症：心煩、舌尖紅，苔黃、脈數。  病機：濕熱下注膀胱，熱盛灼絡，迫血 妄行。  治法：清熱通淋，涼血止血。  主方：小薊飲子合導赤散。

2. 血淋：  虛證  症狀：尿色淡紅，疼痛澀滯不甚顯著。  兼症：腰酸膝軟，神疲乏力，舌淡紅， 脈細數。  病機：腎陰不足，虛火擾動陰血。  治法：滋陰清熱，補虛止血。  主方：知柏地黃丸。

3. 膏淋：  實證  症狀：小便混濁如米泔水，尿道熱澀疼痛。  兼症：舌紅，苔黃膩，脈濡數。  病機：濕熱下注, 阻滯絡脈，脂液不循常道。  治法：清熱利濕，分清泄濁。  主方：程氏萆薢分清飲。

3. 膏淋：  虛證  症狀：淋出如脂，澀痛反見減輕。  兼症：形瘦、頭昏、乏力，腰疲膝軟。舌淡 苔膩，脈細弱無力。  病機：腎虛下元不固，不能制約脂液。  治法：補虛固澀。  主方：膏淋湯。 ( 生山藥 生芡實 生牡蠣 大生地 黨参 芍藥 )

4. 石淋  症狀：尿中時夾砂石，小便艱澀，尿時疼痛 或突然中斷。  兼症：腰腹絞痛難忍，尿中帶血。舌質紅， 苔薄黃，脈弦或帶數。  病機：濕熱煎熬尿液，結為砂石。  治法：清熱利濕，通淋排石。  主方：石葦散。 ( 通草 王不留行 滑石 當歸 …)

5. 氣淋  實證  症狀：小便澀滯，淋瀝不宣。  兼症：少腹滿痛，脈沈弦。  病機：氣機鬱結，膀胱氣化不利。  治法：利氣疏導。  主方：沈香散。 ( 沉香 木香 枳殼 )

5. 氣淋  虛證  症狀：少腹墜脹，尿有餘瀝。  兼症：面色晄白，舌質淡，脈虛細無力。  病機：氣虛下陷。  治法：益氣升提。  主方：補中益氣湯。

6. 勞淋  症狀：小便不甚赤澀，但淋瀝不已，時作時 止，遇勞即發。  兼症：腰痠膝軟神疲乏力，舌淡，脈弱。  病機：脾腎兩虛，濕濁留戀不去。  治法：健脾益腎。  主方：無比山藥丸。 ( 薯蕷 肉蓯蓉 五味子 菟絲子 杜仲 牛膝 澤瀉 乾地黃 山茱萸 茯苓 巴戟天 赤石脂 )

病因 – 中醫觀點  虛 亂 鬱 結 1. 氣血不足 2. 脾腎不足 氣血瘀滯、痰 濁結聚、邪毒 蘊結 七情內傷 外感六淫 喜怒憂思悲恐驚 風寒暑濕燥火

中醫觀點  致病機轉： 邪 病位 致病 濕熱，痰瘀 膀胱（腎） 淋證 1. 外邪致病 病因 2. 素體臟腑功能不協調 3. 情志不調

間質性膀胱炎的中醫證型分類  脾肺氣虛，下焦濕阻  脾腎陽虛，膀胱氣化不利  肝氣鬱滯，肝經氣滯血瘀

針灸對骨盆腔疼痛的療效  西方醫學許多相關研究都證實有效

Effects of acupuncture for chronic pelvic pain syndrome with intrapelvic venous congestion: preliminary results.  出處 - Int J Urol Aug;11(8):  Abstract  BACKGROUND: The present study was designed to reveal the usefulness of acupuncture for chronic pelvic pain syndrome with intrapelvic venous congestion as evaluated by symptom scores, transrectal ultrasonography (TRUS) and magnetic resonance (MR) venography.  METHODS: Ten male patients suffering from non-inflammatory chronic pelvic pain syndrome (NIH category IIIB) with intrapelvic venous congestion were treated using acupuncture. Eight patients had previously received pharmacotherapy, which was unsuccessful. Acupuncture was performed using disposable stainless steel needles, which were inserted into the bilateral BL-33 points and rotated manually for 10 min. The treatment was repeated every week for 5 weeks without other therapeutic maneuvers. Results from TRUS and MR venography, as well as clinical symptoms based on the NIH chronic prostatitis symptom index (NIH-CPSI) and the international prostate symptom score (IPSS), were compared before and after the treatment.  RESULTS: No side-effects were recognized throughout the treatment period. The average pain and QOL scores of the NIH-CPSI 1 week after the 5th acupuncture treatment decreased significantly (P < 0.05 and P < 0.01, respectively) compared with the baseline. The maximum width of the sonolucent zone 1 week after the 5th treatment also decreased significantly (P < 0.01, compared with the baseline). Intrapelvic venous congestion demonstrated by MR venography was significantly improved in four patients.  CONCLUSION: This study provided novel information concerning the therapeutic effects of acupuncture on non-inflammatory chronic pelvic pain syndrome.

Changes in the findings of intrapelvic venous congestion using transrectal ultrasonography before and after acupuncture. Transrectal sonograms of the prostate show the changes in a patient before (a) and after acupuncture (b). The arrows show the dilation of the sonolucent zone. The maximum width of the sonolucent zone is 4.5 mm before and 1.3 mm after acupuncture. Changes in the findings of intrapelvic venous Congestion using magnetic resonance (MR) venography before and after acupuncture. MR venography images show the changes in a patient before (a) and after acupuncture (b). The arrows show the findings of intrapelvic venous congestion before acupuncture. After acupuncture these findings are not shown. IPV, interruption of the internal pudendal veins; PCV, dilation of the prostatic capsular veins; VPB, dilation of the venous plexuses behind the bladder. a b a b

Acupuncture versus sham acupuncture for chronic prostatitis/chronic pelvic pain.  出處 - Am J Med Jan;121(1):79.e1-7.  Abstract  BACKGROUND: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) afflicts 2%-10% of adult men. Available therapies offer little or no proven benefit. Because acupuncture represents an attractive "natural" therapy, we compared the efficacy of acupuncture to sham acupuncture for CP/CPPS.  METHODS: Participants met US National Institutes of Health (NIH) consensus criteria for CP/CPPS, were aged > or = 20 years old, and had a total score > or = 15 on the NIH Chronic Prostatitis Symptom Index (NIH-CPSI) and symptoms for at least 3 of the preceding 6 months. They were randomized 1:1 to acupuncture or sham acupuncture. Treatment consisted of twice-weekly 30-minute sessions for 10 weeks (20 sessions total) without needle stimulation, herbs, or adjuvants. The primary response criterion was a 6-point decrease from baseline to week 10 in NIH- CPSI total score (range 0-43).  RESULTS: Thirty-two (73%) of 44 participants responded in the acupuncture group compared with 21 (47%) of 45 sham group participants (relative risk 1.81, 95% confidence interval, , P =.02). Long-term responses 24 weeks after completing therapy without additional treatment occurred in 14 (32%) of 44 acupuncture group participants and in 6 (13%) of 45 sham group participants (relative risk 2.39, 95% confidence interval, , P =.04).  CONCLUSIONS: After 10 weeks of treatment, acupuncture proved almost twice as likely as sham treatment to improve CP/CPPS symptoms. Participants receiving acupuncture were 2.4-fold more likely to experience long-term benefit than were participants receiving sham acupuncture.

Success of acupuncture in the treatment of painful bladder syndrome (interstitial cystitis)  出處 - The Journal Of Urology Vol. 181, No. 4, Supplement, Saturday, April 25, 2009  Painful Bladder Syndrome (Interstitial Cystitis) (PBS/IC). Is an important clinical condition of unknown aetiology and affects between 0.01% and 0.5% of the female population. The goal of management is to ameliorate the associated pain and storage symptoms and improve quality of life. Available evidence on conservative and supportive therapy suggests limited efficacy for most therapies. Our objective was to determine how effective acupuncture is at reducing symptoms and improving quality of life in a group of individuals who had failed to respond to conventional conservative therapy.

Effectiveness of acupuncture in patients with category IIIB chronic pelvic pain syndrome: a report of 97 patients.  出處 - Pain Med Apr;11(4): Epub 2010 Jan 22.  Abstract  OBJECTIVE: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is of significant interest in urology and unfortunately, the therapy modalities recommended are not fully effective. Therefore, we undertook a pilot study to determine whether acupuncture improves the pain, voiding symptoms, and quality of life in men with category IIIB CP/CPPS.  DESIGN: Prospective, one-group trial, cohort study.  SETTING: Outpatient urology clinic.  PATIENTS AND INTERVENTIONS: Ninety-seven CP/CPPS patients received six sessions of acupuncture to the BL-33 acupoints once a week. The National Institute of Health Chronic Prostatitis Symptom Index (NIH-CPSI) was completed by each patient before and after the treatment and on 12th and 24th weeks following the treatment.  OUTCOME MEASURES: Mean values of total CPSI score, pain subscore, urinary subscore, and quality of life subscore after the treatment and on follow-up after the treatment were compared with the baseline values.  RESULTS: There was a statistically significant decrease in all of the subscores evaluated at all periods compared with the baseline. Eighty-six patients out of 93 (92.47%) were NIH-CPSI responders (more than 50% decrease in total NIH-CPSI score from baseline) at the end of the treatment.  CONCLUSIONS: The results of this study suggest that acupuncture appears to be a safe and potentially effective treatment in improving the symptoms and quality of life of men clinically diagnosed with CP/CPPS.

常用穴位 — 陰陵泉  在小腿內側，脛 骨内側髁下缘凹 陷處。  脾經合穴  運中焦、化濕滯、 調膀胱、袪風冷

常用穴位 — 三陰交  内踝尖直上四横指，脛 骨後緣。  肝、脾、腎  補脾土、助運化、通氣 滯、疏下焦、調血室精 宮、袪經絡風濕

常用穴位 — 陽陵泉  屈膝 90 度，在膝蓋外側 可見到兩個突起，前上 方為脛骨小頭，後方偏 下的是腓骨小頭，兩點 連線作一正三角形，第 三點即為該穴。  膽經合穴  疏泄肝膽、清利濕熱、 疏筋健膝

常用穴位 — 關元  在任脈上，肚臍至 恥骨的距離是五吋 ， 關元穴約在肚臍下 3 吋  交會穴（墓穴）  男子藏精、女子蓄 血之處  益腎氣、利下焦、 回陽救逆

常用穴位 — 太衝  太衝穴位于足背側 ，第一、二趾蹠骨 連接處。以手指沿 拇趾、次趾夾縫向 上移壓，壓至能感 覺到動脉應手，即 是此穴 。  肝經原穴  平肝熄風、清熱利 膽、明目

臨床觀察小結（中醫觀點）  患者除 IC 之外，均有其他免疫系統失調疾病， 例如，上呼吸道過敏、皮膚過敏 ……  腸胃功能障礙亦見於 80 ％以上病患。  少數病患還有患有不同程度的風濕性病變。  不同程度情緒障礙同時伴隨出現。  女性病患病情會隨月經週期而波動。

臨床觀察小結（中醫觀點）  膀胱是身體的一部份，不是獨立存在的臟器。  間質性膀胱炎是全身性的疾病在膀胱的表現。而全 身性的疾病偏表現於呼吸道及消化道的失調，以中 醫的眼光看來，這些部位與膀胱有著內在的聯繫。  間質性膀胱炎似乎與免疫系統失調強烈相關。  治療間質性膀胱炎的同時，應治療全身性免疫系統 的不協調 → 治療全身臟腑關係的失衡

治療經驗總結  間質性膀胱炎的表現，在許多方面來看，與過敏疾 病有很多相似的表現。  過敏體質是不容易改變的，只有在青春期 、 懷孕時 或更年期時有機會轉變。  過敏反應多由特定的刺激所引發。而引發間質性膀 胱炎急性發作的刺激原現今並不清楚，我們只知可 能與壓力 、 憋尿、月經週期（排卵期、月經期）、 感冒或腸胃功能不穩定有關。

治療經驗總結  經過長期觀察，中藥藥物介入治療可以減少 發病頻率，縮短發病時間，減少病情嚴重程 度。  針灸可有效緩解骨盆腔疼痛，效果持續時間 較短暫，每週宜施針 2-3 回。

中西醫整合治療間質性膀胱炎  自民國 101 年 5 月開始至今  在每週二下午，以整合門診討論方式進行個 案研討  各科相關專題報告  營養科、精神科、中醫科、泌尿科、麻醉科、 免疫風濕科、婦科 …

治療模式  初診  詢問病史 建立病患體質模式  複診 現在症狀表現  分析病情 辨邪正，病位，病勢  決定治療方向  處方

治療模式  以教學及研究為目的  以內服藥物（湯藥）為主  未來考慮建立 “ 針灸治療間質性膀胱炎 ” 計畫。

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